Opinion: Sometimes they blame themselves. How to help grieving kids who lost parents to COVID

This opinion piece was authored by Julie Kaplow, PhD, ABPP, Executive Director of the Trauma and Grief Center at The Hackett Center. It was originally published by the Houston Chronicle on December 12, 2021. 

Lucia, a 9-year-old girl, experienced the deaths of both her father and grandmother over a period of three months due to COVID-19. Because these losses occurred in the midst of the pandemic, Lucia was not able to say goodbye to her father or her grandmother, who was her primary caregiver, nor was the family able to have a proper funeral. Following the deaths, Lucia was inconsolable, yearning and longing for both her father and grandmother, and experienced high levels of self-blame, fearing that she may have transmitted the virus to her family members. Because the family was at this point so cautious and maintaining social distance at all costs, Lucia was increasingly isolated. After learning about teletherapy services offered by a mental health center I direct, Lucia began working with a therapist who helped her to identify and work through her active suicidal thoughts, which had led her to fantasize about reuniting with her father and grandmother in heaven. The therapist helped Lucia find healthier ways to feel connected with her father and grandmother and to make meaning of their deaths in a culturally sensitive and age-appropriate way.

Due to the staggering number of COVID-related deaths in this country, we are now facing a silent epidemic of grief in children, or what I refer to here as “psychological long COVID.” At the request of her family, I used “Lucia” in place of the child’s name and changed other identifying information to protect her privacy while still giving a clear picture of how the psychological toll of the pandemic on our nation’s children will be significant and long-lasting. Across the nation, over 167,000 children experienced the death of at least one parent or caregiver to COVID, including 25,630 youths in Texas alone. In fact, Texas is one of the top four states for rates of caregiver loss. The majority of these losses have taken place among Black and Hispanic families, many of whom were facing racial health disparities and higher death rates even prior to the pandemic, making them even more vulnerable to mental and behavioral health issues. In fact, a new U.S. Surgeon General’s Advisory outlines the pandemic’s unprecedented impacts on the mental health of youths across America, as well as the mental health challenges that our youths have faced even prior to the pandemic.

Following the death of a loved one, most children are resilient and will naturally experience “good grief” — finding healthy ways of connecting to the person who died and making meaning of their death over time. However, many children who have experienced deaths due to COVID, especially those with histories of prior traumas or losses, are more likely to develop psychological long COVID, involving a host of grief-related psychological or behavioral problems.

The sudden death of a loved one is the strongest predictor of poor school outcomes, above and beyond any other form of trauma including physical abuse or sexual abuse.

These youths are also more likely to experience post-traumatic stress, depression, anxiety and risk-taking behaviors. Although we do not yet have enough data to know how long psychological long COVID may last, studies show that traumatic losses in childhood can lead to a wide range of problem outcomes in adulthood, including relationship difficulties, substance abuse, prolonged grief disorder, depression and suicide risk. This speaks to the need to identify “at-risk” bereaved youths as quickly as possible and provide early intervention.

Susan Hillis, the author of a National Institutes of Health report, told the Houston Chronicle, “With love, affection and support from the remaining parent … there’s plenty of hope, provided those children get the help they need when they need it.” The problem is, many adults struggle to know when and how to help a grieving child.

Children typically grapple with three primary challenges after the death of a loved one. First, they may really miss the person and long to have them back. Second, they may feel lost without the person or unsure of how they will get through life without the person. Third, they may be very preoccupied with the way the person died.

Fortunately, there are a number of things that adults can do to help with these challenges. They can help children find ways to feel connected to the person who died or engage in activities that the person enjoyed. They can talk openly with children about the person such as saying their name or sharing happy memories. They can help identify positive traits or characteristics that the children have in common with the person and discuss how to carry on the person’s legacy by focusing on those traits and behaviors. Children’s concerns regarding the circumstances of the death often stem from unanswered questions. Did they suffer? Were they afraid? Adults can help by allowing children to ask any questions they may have and providing simple and straightforward answers.

We’ve seen firsthand how these types of interventions can help at our center. A 12-year-old girl who experienced the death of her father to COVID was consumed with sorrow and hopelessness about her future, believing she could never get through life without her father and his support. Over time, and with encouragement from her mother, she began to think that he would want her to live life to the fullest and started doing things that she knew would make him proud, stating, “He wouldn’t want me to be sad all the time. He would want me to enjoy my life and accomplish the things he never did, like graduate from college.”

A 14-year-old boy who experienced the death of his mother due to COVID was very preoccupied with the idea that his mother died all alone in the hospital, and he never had a chance to say goodbye. With the support of his therapist, he was able to write a letter to his mother, saying everything he had wanted to say, as well as a comforting letter that he imagined his mother would write in response. He also began to find ways of feeling more connected to his mother, including making her favorite meal, keeping a piece of her jewelry in his pocket, and with help from his father, identifying all of the positive traits he has in common with his mother.

While most bereaved children will benefit from adult support alone, certain “red flags” may indicate the need for a more thorough evaluation and possible therapy. These include significant behavior changes that cause impairment in daily functioning — in younger children, this may take the form of trouble eating or sleeping or separation anxiety such as refusing to leave a caregiver’s side. For older children or adolescents, this can involve constant tearfulness, extreme social withdrawal or excessive risk-taking behaviors such as drug use and reckless driving. Other red flags to look for include signs of post-traumatic stress such as nightmares, not wanting to talk about the person, hypervigilance or appearing numb. Finally, any expression of a wish to die would require immediate attention from a trained clinician.

Lucia, who has successfully completed treatment, is now a major advocate in her school for masking and vaccinations. She is working to protect her peers from the COVID-related losses that she experienced, as a means of transforming the circumstances of her family members’ tragic deaths into something that can prevent others from suffering in the same way.

Although discussions of long COVID have focused almost exclusively on the physical health impact of the virus, it is time that we pay attention to the equally detrimental psychological long COVID that bereaved children are likely to experience. Collectively, we have the ability, and societal responsibility, to identify and support our nation’s grieving children, and in doing so, ensure the long-term well-being of our most vulnerable youths.

The article is available online here.